3775 APPLICANT L IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
r. - PERMIT NUMBER
13UILDINGPROJ CTIDENTIFICATION.
BUILDING _ APPLICATION & PERMIT 7 q
.ADDRESS 1 1 J
7 BUILDING ELECTRICAL-'PLUMBING-MECHANICAL _
OWrvEme - PLAN CHECK VALIDATION
NAME OTY. ELECTRIC PERMIT
, �• PH ON ,
ON+n q'S
NAts" - OUTLETS-SWITCHES-RECEP 5.00/1.00 r
I C.NO, LIGHTING FIXTURES 5.00/1.00 re rid /
r-orvTR.Ac oR's APPLIANCES-RESIDENTIAL 4.00 f I�
AODR s
t 11bPHON �� PANELS 5. DATE OF APPLICATION
ARCHIT C . SIGNS ��,�• 5A0 PLAN CHECK FEE P.C.N0.
OR
' ENGINEER
LIC.No. SIGNS
ARCH.OR ENG. _ SPECIAL f.•IRGIJIT '5.00 _ PERMIT VALIDATION
ADDRESS
n
'
ZIP EMP:METER OR POLE INS. 15.00
APPLICANTEE ' MOTORS. SEE FEE SCH.
ADDR E55 #7 I fe"
C ,r./V„'` -SE VICE CHANGE 10,00
O o_ LICENSED CONTRACTORS DECLARATION
v G 1 hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
I < u (commencing with Section 7000)of Division 3 f the Busingand BLDG. ELECT. PLG. MECH.
r i Professions Cod n _ 'cense is in full'for fl - ❑
G00. o License Class Lia Number p - ` ❑ ❑ - ❑
y H w Date Contracmr
a y BUILDING PERMIT
¢ ¢ OWNF.R-BUILDER DECLARATION INFORMATION
E oa ° MISC.- REFER TO ORD
X 3 I hereby affirm that I'am exempt[cont the Contractor's Lic e VALUATION S/FT.'
H w o j Law for the following reason.(Sec.7031.5,BusinessandProfessions PERMIT ISSUANCE 6.00
Code:Any city or county which requires permit to construct,alter,
R ce Q p improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO.
ELEC.
n w m R requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
he is licensed pursuant to the provisions of the Contractor's License
Law(Chapter 9(commencingwith Section 7000)of Division 3 of the
a Business and Professions Code)or that he is exempt therefromandOTY. PLUMBING PERMIT FEE
Or I- o lhe'basis for the alleged exemption:Any violation of Section 7031.5 ASTORIEV CONSTR.
a ;°1 by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN&VENT-WATER MA.) 4.00
of not more than five hundred dollars(5500).): ^
❑ Las owner the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 2.00 OCC.GRRES.UNITS
their sole compensation,will do the work,and the structure is not
intended or offered for sale(Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00
Code:The Contractor's License Law does not apply to an owner of.
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 4.00 TALACREAGE
meets a'or through his own employees,provided that such improve-
ments .orthtintended oroffered emplofor,sale,proofed that such
building GAS-EA.SYSTEM-1.INC.4OUTLETS 4.00
or improvement is sold within one year of completion,the owner GAS-EA.SYSTEM-OVER 4(EA.) 1.00 BUILDING USE
builder will have the burden of proving[ha[he did not build or int- RES IND CON PB Omer
prove for purpose,of sale.). INDUSTRIAL WASTE INEl TER. "' 20.00 �. 13 1:1❑ 1,as owner o'the property,am exclusively contracting with
licensed contractors to construct the project(Sec.7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO. -
and Professions Code:The Contractor's License Law does not apply
to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a contmctor(s)licensed pursuant to
the Contractor's License Law, SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ I am exempt under Sec. .BAP.C.for this WATER HEATER W/VENT 4.00
reason
Date - Owner WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORK B RS'COMPENSATION DECLARATION WATER TREATING EQUIP. 4.00
I hereby affirm that 1 have a certificate of convent to wif-m,mn,, ZONING ENG.SITE NO.
of a certificate of Workers'Compensation Insurance,o ace tificd "
co�pj 1� r 5 8 1. .C*' ������'I�J� 1 -
0 P'� Ce i copy is hereby fur shed. - FIRE SPRINK ENERGY T-24
Z Z ❑ 'Certified cop filed I the city inspection division. MISC. REFER TOORD. y`� N❑ Y ❑ N❑
O Applicant _
ccy
CC - CERTCAT OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 6.00 FLOOD ZONE A,L.U,C.
i
LU COMPENSATION INSURANCE PLG.CONTR. - - LIC.NO. .PLG.
IL Cl (This Section need not,be completed if the permit_is I'or one TOTAL Y❑ N❑ V ❑ N❑
::) Z hundred dollars($100)or less)
U O t I certify that in the performance of the work for which this per- OTV MECHANICAL PERMIT FEE FEE SUMMARY
LL H mit is issued,I shall not employ any person in any runner so IS to
O W become subject to the Workers'Compensation Laws of California. . •�O
DQ. ale Applicant ALTER OR ADD TO MECH. 4.00 BUILDING
} W NOTICE TO APPLICANT: If,after making this Certificate of Ex- ,
� Z emption,you should become subject to the Workers'Compensation APPLIANCE 4.00 (PLAN CHECK
-provisions of the Labor Code, you must forthwith comply with
md ' AIR HANDLING UNIT(TO 10 GF.M.) 3.00 FEE
Vsuch provisions or this pernrB shall be deeerevoked.
'CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10MC.EM) 5.00 SEISMIC FEE S�
I hereby affirm that there is a"construction lending agency for EXHAUST HOOD (WITH DUCT) 2.00
the performance'of the work'for which this permit is issued(Sec.- MICROFILM
3097,Cie.CJ. - HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lenders Name HEATI NG UN IT(OV ER 100,000 B.T.U.)7.50 ELECTRIC -
Lcnder's Address
I certify that l haveread this application and state that theabove VENTILATION FAN'(SINGLE) 3,00
information is correct.I agree to comply with all city and county PLUMBING
1 BOILER-COMP(3 H.P.or 100,000 B.T.U.) 4.00
ordinances and state'laws relating to building construction, and
'hereby authorize representatives of this city to enter upon the BOILER-COMP'(Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes,
(We) agree tosave. Indemnify and keep harmless the City o1 MISC. REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 3.00 CONST.TAX
_
may in any y accrue against said City in consequence of the '
granting o1't pq(dtlt. /' , J� MECH.CONT. LIC.NO. MECH. _-
!K/r/A�, (/!/r T°Tn`It ' TOTAL
Signature of Applicant/Contractor �" Date _ '
OFFICECOPY